A home health nurse is caring for a child who has Lyme disease.

Which of the following is an appropriate action for the nurse to take?

Choice A option

Fibrinogen level: Fibrinogen is a protein involved in the blood clotting process, but in this case, it is not appropriate because is not the primary laboratory test used to monitor warfarin therapy. Monitoring fibrinogen levels is more relevant in assessing bleeding disorders or certain medical conditions.

Choice B option

PTT (Partial Thromboplastin Time): PTT is another laboratory test used to evaluate blood clotting function, particularly the intrinsic pathway of the clotting cascade. PTT is not routinely used to monitor warfarin therapy; it is more commonly used to monitor other anticoagulant medications like heparin.

Choice C option

The nurse should plan to report the client's INR (International Normalized Ratio) to obtain a prescription for the client's daily warfarin. INR is a critical laboratory test used to monitor the effectiveness and safety of warfarin therapy.

Warfarin is an anticoagulant medication commonly prescribed to prevent and treat blood clots. It works by interfering with the body's ability to use vitamin K to form blood clots. Monitoring the INR is essential because it indicates how long it takes for the blood to clot, and it helps determine if the client's warfarin dosage needs adjustment to achieve the desired level of anticoagulation.

Choice D option

Platelet count: Platelet count is essential to assess the number of platelets in the blood, which are crucial for normal clotting. However, platelet count monitoring is not the primary focus when prescribing warfarin. It is typically used to evaluate thrombocytopenia (low platelet count) or other conditions affecting platelet function.

The correct answer is choice D. Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen.

Using nail polish remover around the client can increase the risk of fire and burn injuries.

Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.

The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.

Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.

The client should use water-based moisturizers to soothe the mucous membranes.

Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.

The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.

Some general safety tips for home oxygen therapy are:

• Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
• Do not smoke or allow others to smoke near the oxygen source
• Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
• Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
• Secure oxygen tanks or cylinders to prevent them from falling or rolling
• Use the exact rate of oxygen prescribed by the doctor for each activity
• Check the oxygen gauge or level regularly and call the medical supply company when it is low
• Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
• Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent